Colorectal cancer in Georgia, 2003-2007 [Aug. 2011]

Colorectal Cancer in Georgia, 2003 - 2007
Colorectal Cancer
G e o r g i a C oDl Oer pe cat arl tc amn cee rni tn g oe o fr g iPa , u2 0b0 3l- 2i0 0c7 H e a l t 1h

Acknowledgements
Georgia Department of Public Health Brenda Fitzgerald, M.D., Commissioner
Health Protection Office Patrick O'Neal, M.D., Director
Epidemiology Program Cherie Drenzek, DVM, M.P.H., State Epidemiologist
Chronic Disease, Healthy Behaviors, and Injury Epidemiology Section A. Rana Bayakly, M.P.H., Chief Epidemiologist
Georgia Comprehensive Cancer Registry A. Rana Bayakly, M.P.H., Director Chrissy McNamara, M.S.P.H., Epidemiologist Victoria Davis, M.P.H., Epidemiologist
Health Promotion & Disease Prevention Programs Kimberly Redding, M.D., M.P.H., Director
Georgia Comprehensive Cancer Control Program Tamira Moon, M.P.H., C.H.E.S, Manager
We would like to thank all the facilities in Georgia who contributed data to the Georgia Comprehensive Cancer Registry. Without their hard work, this report would not have been possible.
Funding for this research was made possible (in part) by cooperative agreement award number 1/U58/DP00817-04 from the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Suggested Citation: Davis, V., McNamara, C., Bayakly, A., Moon, T. Colorectal Cancer in Georgia, 2003-2007. Georgia Department of Public Health, Health Protection Office, Chronic Disease, Healthy Behaviors, and Injury Epidemiology, August 2011.

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Introduction
Colorectal cancer is a collective term for cancers of the colon and rectum. Since cancers of the colon and rectum share many common features, they are often referred to as colorectal cancer. The colon and rectum are parts of the digestive system. Together, they form a long, muscular tube called the large intestine. The colon is the first four to five feet of the large intestine and the last four to six inches is the rectum (Figure 1).
Once food is chewed and swallowed, it travels through the esophagus to the stomach. In the stomach, it is partially digested and transferred to the small intestine. The small intestine continues digesting the food and absorbs most of the nutrients. The food then travels to the large intestine. The waste then moves from the colon into the rectum and passes out of the body through an opening called the anus during a bowel movement.
The colon consists of 4 sections (Figure 1):
The first section is called the ascending colon. It begins where the small intestine attaches to the colon and extends upward on the right side of the abdomen.
The second section, the transverse colon, runs across the body from right to the left side of the upper abdomen.
The third section, the descending colon, continues downward on the left side.
The fourth section, the sigmoid colon, named because of its S-shape, joins the rectum and the colon.
Colorectal cancers develop slowly over a period of several years. Most of them begin as a non-cancerous polyp, a growth of tissue on the lining of the colon or rectum (Figure 2). Polyps are also known as adenomas. Over 95 percent of colorectal cancers are adenocarcinomas, which arise from cells that line the inside of the colon and the rectum. Removing the polyp early may prevent it from becoming cancerous.
Colorectal cancer affects both men and women and most often occurs in people over 50 years of age. It is the third most commonly diagnosed cancer and cause of cancer death among Georgian men and women. The Georgia Comprehensive Cancer Registry estimates that over 4,300 new cases of colorectal cancer will be diagnosed statewide in 2009 and about 1,300 Georgians will die from this disease.

Figure 1. Anatomy of the Digestive System and Sections of Colon

Figure 2. Colon Polyp

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Detection and Screening
Screening is the process of looking for cancer in people who have no symptoms of colorectal cancer. Regular screenings for colorectal cancer can find cancer early (when it is most likely to be curable). Screenings can also prevent colorectal cancer by finding polyps and removing them before they turn cancerous. Tests that are used for screening colorectal cancer can by divided into two groups:
Tests that find both colorectal polyps and cancer: These tests look at the structure of the colon to find any abnormal areas.
Flexible sigmoidoscopy During this test, a doctor uses a sigmoidoscope to look inside the rectum and the lower section of the colon. The sigmoidoscope is a flexible lighted tube about 2 feet long with a video camera on the end. Images from the inside of the colon and rectum are displayed on a monitor. The tube is used to detect polyps and if any polyps are found, they are removed. The procedure to remove polyps is called polypectomy
Colonoscopy During this test, a colonoscope is used to look inside the entire length of the colon and rectum. The colonoscope is similar to a sigmoidoscope, but is longer. The doctor may also use the colonoscope to assist with the removal of polyps
Double-contrast barium enema (DCBE) During this test, barium sulfate (chalky liquid) and air are used to show an outline of the colon and rectum. X-ray pictures are taken of the colon and rectum which can show abnormal areas. If any suspicious areas are seen, a colonoscopy may be performed
CT colonography (virtual colonoscopy) This test is a more advanced form of a computed tomography (CT) scan. The CT scan takes multiple pictures of the colon and then combines all the pictures in order to create a 2-dimensional or 3-dimensional view of the inside of the colon and rectum. This test is considered less invasive than the colonoscopy, however if any abnormalities are found, a colonoscopy may be needed in order to determine if a cancer is present
Tests that find cancer: These tests involve testing the stool (feces) for signs that cancer may be present. These types of tests are considered to be less invasive and easier.
Fecal occult blood test (FOBT) Damaged blood vessels from polyps or cancers may release a small amount of blood into the feces. The FOBT detects blood in stool that may not be visible. Before the test, certain medications and foods cannot be consumed because they may interfere with the test. The screening test is given as a take home kit and stool samples are taken and returned to a doctor's office for testing. If the test detects blood, a colonoscopy is performed to determine the source. Other conditions such as hemorrhoids or ulcers may also cause blood to be detected
Fecal immunochemical test (FIT) This test is also used to detect blood in the stool. The FIT is also performed at home but may be easier to use since there are no medication or dietary restrictions that are required to be followed before taking the test (unlike the FOBT). After the stool samples have been collected, the samples are returned to the doctor's office for testing
Stool DNA test (sDNA) Colorectal cancer cells may contain DNA mutations on certain genes. These genes are often shed in the stool, which enables tests to detect them. The sDNA test looks for certain abnormal sections of DNA from cancer or polyp cells. This test is new and how often to be tested has not yet been established

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American Cancer Society Recommendations
for Colorectal Cancer Early Detection
The American Cancer Society recommends that people at average risk for colorectal cancer should begin screening at age 50.
Screening options include:
Tests that find polyps and cancer
Flexible sigmoidoscopy- every 5 years*
Double contrast barium enema- every 5 years*
CT colonography (virtual colonoscopy-) every 5 years*
Colonoscopy- every 10 years
Tests that mainly find cancer
Fecal occult blood test (FOBT)-test every year*+
Fecal immunochemical test (FIT)-test every year+
Stool DNA test (sDNA)- interval uncertain**
*Colonoscopy should be done if tests results are positive
+For FOBT or FIT used as a screening test, the take-
home multiple sample method should be used.
**Combined testing is preferred over either annual FOBT or FIT, or FSIG every 5 years alone
For people with Medicare, the most common colorectal cancer screening tests are covered

According to the Georgia Behavioral Risk Factor Surveillance System (BRFSS):
The percent of sigmoidoscopy/colonoscopy screening and FOBT screening is similar among men and women 50 years of age and older
Adults 65 years of age and older have a significantly higher prevalence of receiving either screening when compared to adults 50 to 64 years of age
The Healthy People 2010 objective was reached for adults age 50 years and older who ever had a sigmoidoscopy/colonoscopy
The Healthy People 2010 objective was not reached for adults age 50 years and older who had a FOBT within the last 2 years

FigurFe i3g.FuPCiregoerluco3ernen.ots3oc.foApydublytsSAexg,eG5e0o+r,gWiah2o00E4v-e2r0H08ad a Sigmoidoscopy/
100 100

50 50

59 59

PeHoTpPa5elre0aegHo%lTet2hpa5et0:ylr0ae1g%l0et2ht0:y10

59 59

Percent Percent

00

MaleMsales

FemFaelemsales

FigurFe i4g.FuPCiregoerluco4ernenots4ocfoApydublytsAaggeeG50ro+u,pW, GhoeoErgviear

Had a Sigmoidoscopy/ 2004-2008

100 100

50 50

53 53

68 68

Percent Percent

00

50-6540-64

65+ 65+

ColOrectal cancer in georgia, 2003-2007

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Figure 5. Percent of Adults age 50+, Who Had a Fecal Occult Blood Test (FOBT) in the Past 2 years, by Sex, Georgia 2004-2008
Figure 5
Figure 1500
100

Percent Percent

50 50

26 26

Healthy People 2010 Target: Healthy P5e0o%ple 2010 Target: 50%

26 26

0 Males
0 Males

Females Females

FFigiugruer6e. P6ercent of Adults age 50+, Who Had a Fecal Occult Blood Test Figure 6 (FOBT) in the Past 2 years, by Age Group, Georgia 2004-2008

50

50
25 25

24 24

29 29

Percent Percent

0 50-64
0 50-64

65+ 65+

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Incidence and Mortality

The overall age-adjusted colorectal cancer incidence rate in Georgia is 48 per 100,000 in males and females combined. Males are 39% more likely to be diagnosed with colorectal cancer than females (age-adjusted rate 57/100,000 vs. 41/100,000)
The overall age-adjusted colorectal cancer mortality rate in Georgia is 17 per 100,000 in males and females combined. Males are 40% more likely to die of colorectal cancer than females (age-adjusted rate 21/100,000 vs. 15/100,000)
In Georgia and the U.S., non-Hispanic black males and females are more likely than non-Hispanic white males and females to be diagnosed with colorectal cancer.
Black males are more likely than white males to die of colorectal cancer in Georgia and the U.S. Similarly, black females are more likely than white females to die of this disease
The overall age-adjusted colon cancer incidence rate in Georgia is 35 per 100,000 in males and females combined. Males are 32% more likely to be diagnosed with colon cancer than females (41/100,000 vs. 31/100,000)
The overall age-adjused colon cancer mortality rate in Georgia is 14 per 100,000 in males and females combined. Males are 42% more likely to die from colon cancer than females (17/100,000 vs. 12/100,000)

Figure 7. Age-adjusted Incidence Rate by Race and Sex, 2003-2007

Rate per 100,000

Georgia, 2003-2007 United States, 2003-2007

80

68 68

70

60

50

40

30

20

10

0

Non-Hispanic Black Males

55 57

52 51

38 42

Non-Hispanic Non-Hispanic Non-Hispanic White Males Black Females White Females

Georgia, 2003-2007 United States, 2003-2007 100

Rate per 100,000

Figure 8. Age-adjusted Mortality Rate by Race and Sex, 2003-2007

50 29 31

19 21

0 Black Males

White Males

20 21

13 14

Black Females

White Females

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Causes and Risk Factors
A risk factor is anything that increases the chance of getting a disease such as cancer. Different cancers have different risk factors. Although it is hard to measure the contribution of a risk factor or know the exact cause of precancerous polyps or cancer, some factors may increase the risk of colorectal cancer development. However, some individuals develop colorectal cancer in the absence of any apparent risk factors.
Lifestyle-Related Risk Factors
Diet: A diet high in red meats (beef, lamb, or liver), processed meats, and animal fat, or low in calcium, fiber, and folate may increase the risk of developing colorectal cancer. Also, cooking meats at high temperatures such as frying, grilling, or broiling may increase cancer risk. Diets high in vegetables and fruits have been linked with a decreased risk of colorectal cancer. More research is needed to better understand how diet affects colorectal cancer risk
Physical inactivity: There is a greater chance of developing colorectal cancer if a person is not physically active. Participating in regular physical activity may reduce this risk. To gain substantial health benefits, the U.S. Department of Health and Human Services recommends 2 hours and 30 minutes of moderate-intensity aerobic physical activity each week (i.e. 30 minutes, 5 times a week) for adults.
Obesity: People who are obese have an increased risk of developing colorectal cancer and an increased risk of dying of colorectal cancer when compared to people who are considered to be at normal weight.
Smoking: Long term smokers are more likely than non-smokers to develop and die from colorectal cancer.
Alcohol consumption: Heavy use of alcohol may increase the risk of developing colorectal cancer. The American Cancer Society recommends that alcohol use should be limited to no more than 2 drinks per day for men and 1 drink per day for women.
Diabetes: People with Type 2 diabetes have an increased risk of developing colorectal cancer. They may also have a less favorable prognosis after diagnosis.

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Risk Factors You Cannot Change
Age: The risk of developing colorectal polyps and cancer increase with age. More than 90% of people diagnosed with colorectal cancer are older than 50.
Family history: Parents, siblings, and children of a person who has had colorectal cancer or adenomatous polyps are more likely to develop colorectal cancer. The risk increases if any first-degree relative is affected at a young age or if more than one first-degree relative is affected. Cancers diagnosed frequently within the same family may also be due to inherited genes, shared exposure to environmental carcinogens, diet, or lifestyle factors.
Inherited syndromes: Certain genetic syndromes can increase the risk of developing colorectal cancer. These syndromes cause 5%-10% of all colorectal cancers. The 2 most common syndromes are familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer (HNPCC). People with FAP develop hundreds or thousands of polyps in their colon and rectum in their teens or early adulthood. Cancer may develop in these polyps as early as age 20. Similar to FAP, HNPCC develops when people are relatively young. However, individuals with HNPCC have fewer polyps and develop colorectal cancer at an average age of 44.
Racial and ethnic background: African Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the United States. The reason for this is not yet understood.
Personal history of colorectal cancer or polyps: A person who has had colorectal cancer is more likely to develop new cancers in other areas of the colon or rectum. Some types of polyps, such as adenomatous polyps and hyperplastic polyps increase the risk of colorectal cancer.
Personal history of bowel disease: Inflammatory Bowel Disease (IBD), which includes Ulcerative Colitis and Crohn's disease, is a condition in which the colon is inflamed over a long period of time. People with IBD have an increased risk of developing colorectal cancer and should be screened for colorectal cancer on a more frequent basis.

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Prevalence of Behavioral Risk Factors

Risk Factors Obesity Smoking Physical Inactivity Diabetes

Table 1: Prevalence (%) of Colorectal Cancer Risk Factors, Behavioral Risk Factor Surveillance System (BRFSS), 2009

Georgia

United States

All

Males

Females

All

Males

28

28

27

27

29

18

20

16

18

20

24

21

27

24

22

10

10

9

8

9

Females 26 17 26 8

According to the Georgia 2009 Behavioral Risk Factor Surveillance System (Table1): The prevalence of obesity in males and females is similar Males are more likely to be current smokers than females, however this difference is not significant Females are significantly more likely to be physically inactive than males The prevalence of diabetes is similar in males and females

Symptoms
In the early stages of colorectal cancer, individuals may not have any symptoms. Symptoms usually appear when the disease has advanced. Signs and symptoms of colorectal cancer include:
A change in bowel habits such as diarrhea, constipation, or narrowing of the stool that lasts for more than a few days
A feeling that the bowel does not empty completely Rectal bleeding or blood in the stool Persistent cramping or abdominal pain Weakness and fatigue Unexplained weight loss
Other conditions such as hemorrhoids and inflammatory bowel (IBD) disease may also have symptoms that mimic colorectal cancer. If you have any of the above symptoms, it is very important to talk to your doctor because it could be a sign of a serious medical condition such as colorectal cancer.

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Leading Causes of Cancer Incidence and Mortality

Table 2: Leading Causes of Cancer Incidence and Mortality, Georgia 2003-2007

Top 5 Causes of Cancer Incidence

Top 5 Causes of Cancer Mortality

Males Prostate Lung & Bronchus Colorectal Bladder Melanoma

Females Breast Lung & Bronchus Colorectal Uterus Melanoma

Males Lung & bronchus Prostate Colorectal Pancreas Leukemia

Females Lung & Bronchus Breast Colorectal Pancreas Ovary

Colorectal cancer is the third most commonly diagnosed cancer and cause of cancer death among males and females in Georgia.

Pictured is the Super Colon, which is a 20 foot replica of the human colon. Participants walking through the Super Colon are able to see what healthy colon tissue, non-malignant diseases (i.e. Crohn's disease and colitis), polyps, and different stages of colorectal cancer looks like.

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Age at Diagnosis

Figure 9. Age-specific Colorectal Cancer Incidence and Mortality Rate by Sex, Georgia 2003-2007

Rate per 100,000

400
300
200
100 21
0 0-39

Males

27 7

Incidence Mortality

85 23

182 56

353 282
202
102

40-49 50-59 60-69 70-79

80+

Rate per 100,000

300 250
200 150 100
50 2 1 0
0-39

Females
Incidence Mortality

23 6 40-49

65 16
50-59

118 34
60-69

201 75
70-79

259 141
80+

Males have higher incidence and mortality rates of colorectal cancer in all age groups
The incidence and mortality rates of colorectal cancer increase with age for both males and females (Figure 9)
The risk of being diagnosed with and dying from colorectal cancer increases sharply between ages 50-59 years for both males and females
In both men and women less than 40 years of age, less than 65 cases and 15 deaths due to colorectal cancer occur each year

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Spotlight:
In July 2010, CDC Awarded Georgia a Grant for Colorectal Cancer Screening
The Centers for Disease Control and Prevention has awarded the state of Georgia a grant to provide colorectal cancer education and screening services for low-income residents age 50 years and older, who are underinsured or uninsured. The goal is to increase population-level screening among all persons age 50 years and older and to reduce the incidence and mortality of colorectal cancer, and health disparities in colorectal cancer screening.
According to Laura Seeff, M.D., medical director of CDC's colorectal cancer screening program, "This screening program has tremendous potential to address the disparities that exist in colorectal cancer screening and to save lives."

Treatment
Different types of treatment are available for patients with colorectal cancer. The choice of treatment depends on a variety of factors such as age, overall health, and type and stage of colorectal cancer. The three standard types of treatment used in colorectal cancer are: surgery, radiation therapy, and chemotherapy. Depending on the stage of cancer, multiple treatment modalities may be used at the same time or one after another.
Surgery This is the main treatment for early stage colorectal cancer. If the cancer is found at an early stage, the doctor may remove it without cutting the abdomen by using a colonoscope (a tube that is inserted through the rectum). This procedure is called a local excision. If cancerous polyps are found and removed, the procedure is called a polypectomy. If the polyp is larger, the doctor performs a colectomy which removes a section of the large intestine on either side of the cancer including some lymph nodes and connects the healthy parts of the intestine together. If the doctor is not able to connect the ends of the colon back together, an opening is made in the abdomen and a bag is placed over the opening to collect waste. This procedure is called a colostomy.
Radiation Therapy This treatment uses high energy x-rays to kill cancer cells. There are two types of radiation therapies: external radiation and internal radiation. External radiation comes from a machine and is directed at the cancer. During internal radiation therapy, radioactive material is placed directly into or near the cancer. Radiation therapy can be used to kill any cancer cells remaining that might not have been completely removed by surgery.
Chemotherapy This treatment uses drugs to kill cancer cells. Systemic chemotherapy uses drugs that are injected into a vein or taken by mouth. These drugs enter the bloodstream and reach cancer cells throughout the body. In regional chemotherapy, drugs are placed directly into an artery leading to a part of the body where the tumor is located.
Adjuvant and Neoadjuvant Chemotherapy Adjuvant chemotherapy is used after surgery when there is no evidence of cancer remaining but there is a chance the cancer will return. Neoadjuvant chemotherapy is used for rectal cancers before surgery (along with radiation), to shrink the tumor size. Chemotherapy helps to shrink tumors, relieve symptoms from the tumor, and extend survival for some patients.

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Stages of Colorectal Cancer

Staging is a standardized way to summarize information about how far a cancer has spread and helps determine a treatment plan. The TNM staging system is used at hospitals to guide treatment options, however, many central cancer registries, such as The Georgia Comprehensive Cancer Registry and the National Program of Cancer Registries (NPCR) use SEER summary stage for surveillance purposes, categorizing cancer into these groups:
Localized: Cancer that is confined to the organ where it started
Regional: Cancer that has spread from its primary site to nearby lymph nodes or organs
Distant: C ancer that has spread from its primary site to distant organs or lymph nodes. Also referred to as distant metastasis

Incidence of Colorectal Cancer by Stage of Disease

Table 3: Percent of Colorectal Cancer Found by Stage of Disease, Sex and Race, Georgia (2003-2007) and United States (1999-2006)

Localized (%)

Regional (%)

Distant (%)

US Males

40

37

19

GA Males

37

34

18

US Females

38

37

19

GA Females

38

33

17

US Black Males

35

35

25

GA Black Males

35

31

22

US White Males

40

37

19

GA White Males

38

34

17

US Black Females

35

35

24

GA Black Females

38

30

20

US White Females

38

38

19

GA White Females

38

34

16

The distribution of stage at diagnosis for colorectal cancer patients in Georgia is similar to colorectal cancer patients in the U.S.
*Unknown/unstated category is not shown

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Figure 10. Stages of Colorectal Cancer

The TNM system is based on the size of the tumor (T), the spread of the tumor to the lymph nodes (N), and the presence of distant metastasis (M). The TNM system is then used to determine the stage of the cancer. The stages of colorectal cancer are:

Stage 0: The cancer is found only in the innermost lining of the colon or rectum, also known as carcinoma in situ.

Stage I: The tumor has grown into the inner wall of the colon or rectum. The tumor has not grown through the wall.

Stage II: The tumor extends more deeply into or through the wall of the colon or rectum. It may have invaded nearby tissue, but cancer cells have not spread to the lymph nodes.

Stage III: The cancer has spread to nearby lymph nodes, but not to other parts of the body.

Survival

Stage IV: The cancer has spread to other parts of the body, such as the liver or lung. It may or may not have spread to nearby lymph nodes.

Early detection saves lives. Individuals diagnosed at an early stage (localized) have a better chance of surviving five years after diagnosis than those diagnosed at a later stage (Figures 11 and 12).

Figure 11. C olorectal Cancer Five-Year Survival Rates by Sex and Stage, United States, 1999-2006

Figure 12. Colorectal Cancer Five-Year Survival Rates by Sex, Race, and Stage, United States, 1999-2006

100 90 80 70 65 65 60 50 40 30 20 10 0

90 91

69 70

All Stages Localized Regional

M ales Females
11 12 Distant

100

91 91

90

85 86

80

70

66 66

60 56 57

70 70 63 63

50

40

30

20

10

0

All Stages Localized Regional

Black M ales White M ales Black Females White Females
8 11 9 13
Distant

Overall, the five-year survival rate for the United States is 65% for both males and females at all stages. The five-year survival rate is highest in both males and females when detected at the localized stage
The five-year survival rates for white males and white females for all stages are higher than those for black males and black females
Five-year survival rates drop significantly for individuals when diagnosed at the distant stage

Percent Percent

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Urban vs. Rural Georgia
Figure 13. Metro, Metro Adjacent, and Rural Counties, Georgia 2003

*For a more specific description, please refer to the technical notes

Figure 14. Age-Adjusted Colorectal Cancer Incidence and Mortality Rate by Geography and Sex, Georgia, 2003-2007

Incidence

Males

Females

Males

Females

100

56

50

43

70 45

64 46

65 49

66 46

30

25

20

19

15

14

10

Mortality Males Females

Males

Females

25

22

22

15

15

14

22 16

Rate per 100,000 Rate per 100,000

5

0 Metro 1+ Metro 250K-1M Metro <250K Metro Adjacent

Rural

0

Metro 1+

Metro 250K-1M Metro <250K Metro Adjacent

Rural

Age-adjusted colorectal cancer incidence and mortality rates are consistently higher among males than among females regardless of geographical area
Males living in metropolitan counties (250,000 to 1 million people) have the highest incidence and mortality rates. Males living in metropolitan counties (1 million or more) have the lowest incidence and mortality rates.
Males living in metropolitan counties with a population of 1 million or more have significantly lower incidence rates than males living in all other counties
Females living in metro adjacent and rural counties have significantly higher incidence rates than females living in metro counties with a population of 1 million or more
Mortality rates for males living in metropolitan counties (250,000 to 1 million) are significantly higher than males living in metropolitan counties with a population of 1 million or more
Mortality rates for females are similar among all geographical areas

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Associations between Poverty and Geography
Figure 15. Counties by Poverty Level, Georgia, 2005
*For a more specific description, please refer to the technical notes

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Table 4. Age-Adjusted Incidence Rate, by Sex, Geography and Poverty, Georgia 2003-2007

Level of Poverty

Males

Females

Metro Level

Low

Medium

High

Low

Medium

High

Metro 1M+

55

57

79

42

43

39

Metro 250K-1M

58

67*

77*

39

44

47

Metro <250K

60

63*

66*

41

46

47

Metro Adjacent

-

64

65*

-

51*

47

Rural

-

66*

66*

-

48*

45

Males have consistently higher incidence rates than females (Table 4)
Males living in low poverty metro counties (1 million or more) have significantly higher incidence rates than females living in the same area
Incidence rates are highest in males living in high poverty metropolitan counties (1 million or more)
The lowest incidence rates occur in females living in high poverty metropolitan counties (1 million or more) and low poverty metropolitan counties (250,000 to 1 million)
Among males, regardless of geographical region, incidence rates increase as poverty level increase
In low poverty counties, incidence rates increase as metro level moves from large metropolitan counties to metro (less than 250,000) counties among males
Incidence rates for females living in medium poverty counties increase as metro level moves from large metropolitan counties to metro adjacent counties
Females living in medium poverty rural counties and medium poverty metro adjacent counties have significantly higher incidence rates than females living in low poverty metro counties (1 million or more)

* Rate is statically significantly different ** Less than 20 cases - There were no counties classified as low poverty metro adjacent or low poverty rural

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Table 5. Age-Adjusted Incidence Rate, Males, by Race, Geography and Poverty, Georgia 2003-2007

Level of Poverty

Black

White

Metro Level

Low

Medium

High

Low

Medium

High

Metro 1M+

60

66

140*

57

54

**

Metro 250K-1M

112

85*

92*

54

63

69*

Metro <250K

**

76*

85*

59

63*

59

Metro Adjacent

-

61*

80

-

65

60

Rural

-

78*

73*

-

65*

65*

Black males have consistently higher incidence rates than white males, except black males living in medium poverty metro adjacent counties (Table 5)
Incidence rates for black males and white males living in low poverty metro counties (1 million or more) are similar
Incidence rates for black males living in high poverty counties decrease as metro level moves from large metropolitan counties to rural counties
Incidence rates for white males living in medium poverty counties increase as metro level moves from large metropolitan to rural counties
Incidence rates are significantly higher for black males in metro (1 million or more, 250,000 to 1 million, and less than 250,000) and rural counties living in high poverty, metro (250,000 to 1 million, less than 250,000, and adjacent) and rural counties living in medium poverty compared to black males living in low poverty metro counties (1 million or more)
Incidence rates are significantly higher for white males in metro (250,000 to 1 million) and rural counties living in high poverty and metro (less than 250,000) and rural counties living in medium poverty compared to white males living in low poverty metro counties (1 million or more)

* Rate is statically significantly different ** Less than 20 cases - There were no counties classified as low poverty metro adjacent or low poverty rural

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Table 6. Age-Adjusted Incidence Rate, Females, by Race, Geography and Poverty, Georgia 2003-2007

Metro Level

Low

Metro 1M+

49

Metro 250K-1M

**

Metro <250K

**

Metro Adjacent

-

Rural

-

Black Medium
54 62* 53 66* 63*

Level of Poverty

High

Low

**

41

57

35

57

38

60

-

54

-

White

Medium

High

38

**

39

41

45

40

46

44

47*

41

Black females have consistently higher incidence rates than white females (Table 6)
Black females living in low poverty metro counties (1 million or more) have significantly higher incidence rates than white females living in the same area
The highest incidence rates occur in black females living in medium poverty metro adjacent counties
Incidence rates for white females living in medium poverty levels increase as metro level move from large metropolitan to rural counties
Incidence rates for both black and white females living in medium poverty rural counties are significantly higher than their counterparts living in low poverty metro counties (1 million or more)
Additionally, black females living in medium poverty metro counties (250,000- 1 million and adjacent) have significantly higher incidence rates than black females living low poverty metro counties (1 million or more)

* Rate is statically significantly different ** Less than 20 cases - There were no counties classified as low poverty metro adjacent or low poverty rural

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Table 7. Age-Adjusted Mortality Rate, by Sex, Geography and Poverty, Georgia 2003-2007

Metro Level Metro 1M+

Level of Poverty

Males

Females

Low

Medium

High

Low

Medium

High

19

19

**

14

15

**

Metro 250K-1M

23

25*

26*

9

15

16

Metro <250K

**

22

23

**

14

17

Metro Adjacent

-

23

20

-

15

13

Rural

-

19

25*

-

16

15

Males have consistently higher mortality rates than females (Table 7)
Mortality rates for males living in low poverty metro counties (1 million or more) are significantly higher than females living in the same area
Among males, the highest mortality rates occur in high poverty metropolitan counties (250,000 to 1 million). The lowest mortality rates occur in low and medium poverty metropolitan counties (1 million or more) and medium poverty rural counties
Among females, the highest mortality rates occur in high poverty metropolitan counties (less than 250,000). The lowest mortality rates occur in low poverty metropolitan counties (250,000 to 1 million).
Mortality rates for males living in medium and high poverty metropolitan counties (250,000 to 1 million) and high poverty rural counties are significantly higher than males living in large low poverty metro counties

Table 8. Age-Adjusted Mortality Rate, Males, by Race, Geography and Poverty, Georgia 2003-2007

Level of Poverty

Black

White

Metro Level

Low

Medium

High

Low

Medium

High

Metro 1M+

26

27

**

19

17

**

Metro 250K-1M

**

29

35

23

24

22

Metro <250K

**

29

33

**

21

19

Metro Adjacent

-

35

23

-

20

19

Rural

-

23

32

-

18

22

Black males have consistently higher mortality rates than white males (Table 8)
The mortality rates for black males and white males living in low poverty metro counties (1 million or more) are similar
Black males living in high poverty metropolitan counties (250,000 to 1 million) and medium poverty metro adjacent counties have the highest mortality rates
White males living in medium poverty metro counties (1 million or more) have the lowest mortality rates
Regardless of geographic location or poverty level, mortality rates for black males and white males are similar to their counterparts living in low poverty metro counties (1 million or more)

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Table 9. Age-Adjusted Mortality Rate, Females, by Race, Geography and Poverty, Georgia 2003-2007

Level of Poverty

Black

White

Metro Level

Low

Medium

High

Low

Medium

High

Metro 1M+

21

21

**

13

12

**

Metro 250K-1M

**

21

19

**

13

13

Metro <250

**

23

22

**

13

14

Metro Adjacent

-

23

18

-

11

12

Rural

-

21

20

-

15

13

Black females have consistently higher mortality rates than white females (Table 9)
Black females living in low poverty metro counties (1 million or more) have significantly higher mortality rates than white females living in the same area
Black females living in medium poverty metro (less than 250,000) and metro adjacent counties have the highest mortality rates
White females living in medium poverty metro adjacent counties have the lowest mortality rates
Regardless of geographic location or poverty level, mortality rates for black females and white females are similar to their counterparts living in low poverty metro counties (1 million or more)

* Rate is statically significantly different ** Less than 20 cases - There were no counties classified as low poverty metro adjacent or low poverty rural

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Incidence Trends

Figure 16. Age-adjusted Colorectal Cancer Incidence Rates among Males by Race, Georgia (1998-2007) vs. United States (1999-2007)

US Black Males

US White Males

GA Black Males

GA White Males

Rate per 100,000

90 80 70 60 50 40 30 20 10
0 1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

White males generally have lower incidence rates than black males, in both Georgia and the U.S. Georgia incidence rates are slightly lower than the U.S. incidence rates for black and white males Among U.S. black males, incidence rates declined by 1.2% per year during 1999 to 2007 Among black males in Georgia, incidence rates increased from 1998 to 2001. Since 2001, the rates have
been declining slightly Among U.S. white males, incidence rates declined by 2.4% per year during 1999 to 2007 Incidence rates for white males in Georgia increased from 1998-2002. From 2002 to 2007, incidence rates
have significantly declined at 3.7% per year

Figure 17. Age-adjusted Colorectal Cancer Incidence Rates among Females by Race, Georgia (1998-2007) vs. United States (1999-2007)

US Black Females

US White Females

GA Black Females

GA White Females

Rate per 100,000

60 50 40 30 20 10
0 1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

White females have consistently lower incidence rates than black females, in both Georgia and the U.S. Georgia incidence rates are consistently lower than the U.S. incidence rates for black and white females Incidence rates for black females in the U.S. declined by 1.5% from 1999-2007 Among Georgia black females, incidence rates have been stable since 1998 Incidence rates for white females in the U.S. declined by 2% from 1999-2007 Among Georgia white females, incidence rates significantly declined at 1.5% during 1998-2007

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Figure 18. Age-adjusted Colorectal Cancer Mortality Rates among Males by Race, Georgia (1980-2007) vs. United States (1980-2006)

US Black M ales

US White M ales

GA Black M ales

GA White M ales

50

40

30

20

10

0

Rate per 100,000 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Mortality rates are generally lower among white females than black females, in both Georgia and the U.S.
Georgia mortality rates are consistently lower than the U.S. incidence rates for black and white females
Since 2001, mortality rates for U.S. black females have significantly declined by 3.5% per year
Among black females in Georgia, mortality rates were stable from 1980 to 2007
Among U.S. white females, mortality rates declined significantly from 1980 to 2001 and 2001 to 2006 (1.8% and 3.4% per year respectively)
Since 1980, mortality rates have declined significantly by 1.6% per year among white females in Georgia

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Figure 19. Age-adjusted Colorectal Cancer Mortality Rates among Females by Race, Georgia (1980-2007) vs. United States (1980-2006)

US Black Females

US White Females

GA Black Females

GA White Females

50

40

30

20

10

0

Rate per 100,000 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Mortality rates are generally lower among white females than black females, in both Georgia and the U.S.
Georgia mortality rates are consistently lower than the U.S. incidence rates for black and white females
Since 2001, mortality rates for U.S. black females have significantly declined by 3.5% per year
Among black females in Georgia, mortality rates were stable from 1980 to 2007
Among U.S. white females, mortality rates declined significantly from 1980 to 2001 and 2001 to 2006 (1.8% and 3.4% per year respectively)
Since 1980, mortality rates have declined significantly by 1.6% per year among white females in Georgia

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Mortality Trends
Colorectal Cancer Resources:
You can learn more about colorectal cancer from the following organizations:
American Cancer Society Telephone: 1-800-ACS-2345 (1-800-227-2345) Website: www.cancer.org
Centers for Disease Control and Prevention Telephone: 1-800-CDC-INFO Website: www.cdc.gov
National Cancer Institute, Cancer Information Service Telephone: 1-800-4-CANCER (1-800-422-6237) Website: www.cancer.gov
National Colorectal Cancer Research Alliance Telephone: 1-213-481-3101 Website: www.eifoundation.org/programs/eifs-national-colorectal-cancer-research-alliance
Cancer Research and Prevention Foundation Telephone: 1-800-227-2732 Website: www.preventcancer.org
Cancer Control Planet Website: http://cancercontrolplanet.cancer.gov/
Colon Cancer Alliance Telephone: 1-877-422-2030 Website: www.ccalliance.org
Georgia Comprehensive Cancer Registry Telephone: 404-657-6611 Website: http://health.state.ga.us/programs/gccr/index.asp

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Technical Notes
Definitions:
Age-Adjusted Rate is calculated in a manner that minimizes the effects of differences in age composition when comparing rates derived from populations with different age structures. It is expressed per 100,000 population.
Cancer Incidence Rate is a measure of the development of new cancer cases in a population within a specified period of time. It is expressed as a rate per 100,000 population.
Cancer Mortality Rate is defined as the number of deaths, due to cancer, occurring in a specified population during a specified period of time. It is also expressed as a rate per 100,000 population.
Average Risk Population includes most people who develop colorectal cancer and have no identifiable risk factors. People at increased risk of colorectal cancer consist of those with personal or family history of colorectal cancer, those with colorectal cancer symptoms or those who already have inflammatory bowel disease or certain genetic conditions.
Obesity is defined as a body mass index (BMI) between 30.0 and 99.8.
Smoking is defined as an adult smoking at least 100 cigarettes in their lifetime and is currently smoking.
Physical Inactivity is defined as not participating in any physical activities within last 30 days.
2003 Rural-Urban Continuum Codes: Rural-Urban Continuum Codes form a classification scheme that distinguishes metropolitan (metro) counties by the population size of their metro area, and nonmetropolitan (nonmetro) counties by degree of urbanization and adjacency to a metro area or areas:
1 = Counties in metro areas of 1 million population or more 2 = Counties in metro areas of 250,000 to 1 million population 3 = Counties in metro areas of fewer than 250,000 population 4 = Urban population of 20,000 or more, adjacent to a metro area 5 = Urban population of 20,000 or more, not adjacent to a metro area 6 = Urban population of 2,500 to 19,999, adjacent to a metro area 7 = Urban population of 2,500 to 19,999, not adjacent to a metro area 8 = Completely rural or less than 2,500 urban population, adjacent to a metro area 9 = Completely rural or less than 2,500 urban population, not adjacent to a metro area
The above codes were regrouped into the following categories: 1 = Metro >1M 2 = Metro 250K-1M 3 = Metro <250K 4 = Metro-Adjacent 5 = there are no counties in Georgia that fit category number 5 6, 7, 8 and 9 = Rural
Poverty Codes: The Georgia Comprehensive Cancer Registry categorizes the poverty percent into three groups: Low poverty areas = less than 10% of county's population is below United States poverty level Medium poverty areas = 10%-19% of county's population is below United States poverty level High poverty areas = 20% or more of county's population is below United States poverty level

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Data Sources:
The number of new cases and incidence rates for the state of Georgia were obtained from the Georgia Department of Public Health, Georgia Comprehensive Cancer Registry.
Incidence rates for the United States were obtained from the North American Association of Central Cancer Registries (NAACCR).
The number of deaths and mortality rates for the State of Georgia were obtained from the Georgia Department of Public Health, Vital Records Program.
Mortality rates for the United States were obtained from the North American Association of Central Cancer Registries (NAACCR) and from the Surveillance, Epidemiology, and End Results (SEER) program, National Cancer Institute. The mortality rates for the United States trend analysis were obtained from the National Center for Health Statistics, Centers for Disease Control and Prevention (CDC).
Cancer stage and survival data for the United States were obtained from the Surveillance, Epidemiology, and End Results (SEER) program, National Cancer Institute.
Prevalence of risk factors, such as obesity, smoking, physical inactivity, and diabetes (for the year 2009) and screening for colorectal cancer (average of years 2004, 2005, 2006, 2008) in Georgia were analyzed from the Behavioral Risk Factor Surveillance System (BRFSS), Epidemiology Program, Georgia Department of Public Health. National data for the prevalence of similar risk factors was retrieved from Centers for Disease Control and Prevention at www.cdc.gov/brfss/
Clinical information on colorectal cancer was retrieved from the Mayo Clinic at www.mayoclinic.com , Colorectal Cancer Medline Plus at www.nlm.nih.gov/medlineplus, National Cancer Institute at www.cancer.gov , and the American Cancer Society at www.cancer.org.

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Methods:
Incidence rates were calculated per 100,000 population and age-adjusted by the direct method to the 2000 US standard population. Except where calculated to show trends, the incidence rates are five-year average annual rates for the period 2003 through 2007. Incidence rates are calculated for the non-Hispanic black and non-Hispanic white populations for Georgia. Incidence data were coded using ICD-O-3 codes. The ICD-O-3 codes used for colorectal cancer are C180:C209, C260.
Mortality rates were calculated per 100,000 population and age-adjusted by the direct method to the 2000 US standard population. Except where calculated to show trends, the mortality rates are five-year average annual rates for the period 2003 through 2007. Mortality data were coded using ICD-9 codes (1980-1998) and ICD-10 codes (1999-2007). The ICD-9 codes for colorectal cancer are 153.0154.1, 159.0, while the ICD-10 codes for colorectal cancer are C180:C209, C260.
The estimated number of cases for 2009 was calculated by multiplying age-specific incidence rates for 2003-2007 by age-specific population projections for 2009. The estimated number of deaths for 2009 was calculated by multiplying age-specific mortality rates for 2003-2007 by age-specific population projections for 2009. Population projections were retrieved from the U.S. Census Bureau.
Trend analysis was performed using the Joinpoint Regression Program Software developed and maintained by the National Cancer Institute. Incidence and mortality rates for the United States used in the trend analysis were obtained from the CDC Wonder Database.
The Rural-Urban classification of Georgia counties was based on the 2003 Rural-Urban Continuum Codes from the United States Department of Agriculture, Economic Research Service. Information about the Rural-Urban Continuum Codes can be retrieved from
http://www.ers.usda.gov/Data/RuralUrbanContinuumCodes/.
Poverty data for Georgia was retrieved from the U.S Census Bureau's Small Area Income and Poverty Estimates (SAIPE) Program at http://www.census.gov/did/www/saipe/.

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